? Sally dose confusion again, advice?

[Ter and Sally]

Last week's confusion: http://www.felinediabetes.com/FDMB/threads/sally-dose-change-comment.200817/

This week's confusion:
I will try to be very concise because I tend to ramble in my posts.
First, I don't have the calipers yet but I have checked all my syringes to make sure the line/plunger is at the zero line.
And it continues to haunt me that that back in September when we started Sally on insulin again the first day I gave her PZI, it was a full unit and her BG was 222. I was panicking and not in my right mind that morning and it continues to haunt me because I don't think I should have done that injection. Ever since then, first with PZI then with Lantus we have been on a continuous bounce. The only time we saw no bouncing/more consistant numbers was when we finally started giving her Lantus only once a day. Her AMPS/PMPS would be in the 200's and she would stay in the hundreds for most of the day, and unfortunately we did not test at night but my other half reasons that she had flattened out and since her AMPS again was in the 200's then she must have had decent numbers throughout the night. No pinks/reds/blacks. When I brought this to the attention of an internal med vet (the wife of my vet) she said well, Lantus can last in the system up to 18 hours, maybe you are headed toward remission. Based on those numbers my vet said try her off insulin, which we did and the evening of the 4th day off her appetite was off, the next morning she had ketones, then she spent 4 days in the hospital.
The ER sent us home on a sliding scale dosing, then we came to our senses and said no, that's insane you don't dose Lantus that way. Since .50 brought her to no shooting numbers, and we were afraid to not shott because of her previous ketones, we decided on .25 as our dose. Since then except for a brief period, she has been all over the place.
She did have a couple of low numbers, but that was way out of the ordinary and I attributed that to very inconsistant syringes which at one point had given her a dose close to .50 instead of what we thought we were giving.
Granted, on the once a day she did not see greens, but a variety of blues for a longer amount of time than when we does twice a day. I do not think her body can accept .50 twice a day safely.
I'm really concerned about her kidneys. Since the hospital stay her Specific Gravity is now 1.023. Back in December it was in the 1.040 range. She does not show signs of kidney issues (yet) her kidney/liver values were normal as of her release from the hospital; neither did she ever show classic diabetic signs except for some poor coat quality and wegiht loss. Her weight loss has been more substantial when she was on higher doses of insulin, either Lantus or PZI. The only time she developed ketones was when we took her off completely, and that happened very quick. Obviously she does need insulin.
Still a long post!
I am missing many many night readings, but is there any justification to going back to once a day since ECID? Could she be an exception to the rule? My husband and I keep tossing this around, to no avail because we are so afraid of her not getting enough insulin. But I am also afraid of wearing out her body with constant bouncing. They also gave her big doses of insulin in hospital; I know that is dka treatment, but scary to see that they even had to put her on a glucose drips a couple of times because she went so low. The doctor told us she can obviously tolerate numbers in the 40's and 50's so don't worry about her hitting those......don't intervene if she is not showing signs of hypo. I think that is insane advice.
Does anybody see a trend in her spreadsheet that I am too close to it to see? My fear for her is that by all this craziness of bouncing, and our criminal stopping of insulin that put her in the hospital, we are decreasing the ability of her kidneys to function.
Just looking at her nadir the past few days, one wouldn't lower her dose but should we try what we did before and lower it? Or go back to once a day? We keep telling ourselves you don't base the dose of Lntus on preshot numbers but it is easier to get her to lower nadirs when her preshots are starting lower.
Thanks to anyone who made it thru my post and can give an opinion.

 

[Sienne and Gabby (GA)]

It is common practice for treating DKA to use a lot of insulin (usually a longer acting plus a short acting) and keep the cat on a glucose drip. I would not let that be a concern. Since one of the issues with DKA is not enough food and not enough insulin, the kitty is getting a good dose of insulin and the glucose acts as both food and a means of controlling the insulin.

he doctor told us she can obviously tolerate numbers in the 40's and 50's so don't worry about her hitting those......don't intervene if she is not showing signs of hypo.

I agree. I think that's stupid advice, as well. Many, many cats, my own included, could hit ridiculously low numbers and not show a sign of hypoglycemia. By the time the cat is symptomatic, it's a huge problem.

As I see it, trying to draw conclusions about once a day dosing is based on no PM numbers. Given what you were seeing at AMPS, those pinks were coming from the lack of insulin.

I know you probably hear this a lot. You need more PM test data. My best assumption without benefit of data is that because you've held the 0.25u dose for so long, glucose toxicity has developed. Basically, this means that Sally has gotten used to higher numbers and it makes it harder for the insulin to do it's job. In addition, since Lantus is a gentle insulin, it does better when it comes to flattening out the curve, when numbers are lower, Lantus does better at flattening things out versus some of the other types of insulin which yank numbers down.

You're correct in that with SLGS, you would reduce the dose with a number under 90. If there were PM data, all things being equal, I'd suggest increasing the dose. Decreasing as a means of trying to eliminate bouncing just doesn't work and you end up losing time since you end up having to increase back up.

 

[Ter and Sally]

When I look at early May and see those blue and yellow numbers to me it just looks so much better than what I have now. She would spend hours in blues. Has there been anyone who stayed in yellows and blues and did well? Or after 8 months of Lantus should I try something else? It almost seemed like we were doing ok till I
had a bunch of horrible syringes. My

head is so muddled. When we first started out I had the feeling of getting somewhere good with this now I am afraid to make any move.
I can't even talk about it intelligently anymore.
We are still testing for ketones every day.
My husband really wants to try going to once a day again to try to keep her more consistant.
We have the same discussions every 12 hours. The poor thing knows it's time to eat and get her insulin because she hears raised voices!

 

[Ter and Sally]

A note on last night's dose I forgot to mention. When I drew out the syringe there was some blood, perhaps the injection was too deep. Grasping at straws.

 

[Sienne and Gabby (GA)]

Some cats do better on Levemir. It has a later onset and nadir than Lantus and it still a long-acting, depot type of insulin. However, if you keep Sally at the same dose the way you have been with Lantus and don't get more PM tests, you will likely get the same results. Regardless of whether you follow TR or SLGS, you need to get at minimum, one test each cycle in addition to AMPS and PMPS. Doses need to be adjusted weekly with SLGS (every 3 days with TR) if the numbers aren't where you want them..

 

[Ter and Sally]

Thanks Sienne. So if I'm having what I think of as difficulty with Lantus it sounds like Levemir is not going to be better with it's later action. And since during the daytime the nadir has been at different times and sometimes there's not enough info on the +2 or 3 I guess there's no magical number to check at night. Maybe try different times on different days and treat that as a kind of curve. Sometimes I forget what I've learned. Like checking the syringes.

 

[Sienne and Gabby (GA)]

In fact, testing at various times is recommended until you have a pretty clear idea of what's going on. Gabby had a reliably early onset and nadir, except on those cycles when she didn't. I had to keep reminding myself that the only thing cats seem to be reliable about is their unpredictability.

The reason I never switched to Lev was that Gabby had an early nadir (like around +3). It allowed me to shoot at 5:00 and then have time to get a few tests in before I left for work. Lev would not have given me that latitude.

 

[Ter and Sally]

In fact, testing at various times is recommended until you have a pretty clear idea of what's going on. Gabby had a reliably early onset and nadir, except on those cycles when she didn't. I had to keep reminding myself that the only thing cats seem to be reliable about is their unpredictability.

The reason I never switched to Lev was that Gabby had an early nadir (like around +3). It allowed me to shoot at 5:00 and then have time to get a few tests in before I left for work. Lev would not have given me that latitude.

I'm lucky to have my husband here to check her duing the day, that's why so many day tests. I'm the one who draws and shoots, we actually both are involved in getting the dose right to double check. He crunches the numbers and feeds if she drops fast or looks like she is going to bounce. He has the real "feel" for what she may do next, and for the most part he turns out to be right.
I have about an hour commute to work, not reliable because traffic is so bad. We used to do 7 am/7pm but then my hours and commute got so unpredicatable we started the 7:30/7:30. I get up, get ready, he tests, I shoot, and I'm out the door. Same thing at night, get home, shower, test, shoot, eat, go to bed.
We have had another major upset in the house today--just an hour ago we found out that my mother in law is in the hospital in VA with bacterial meningitis. 50/50 chance. We don't know what is going to be happening in the next couple of days. Maybe it will help us not to overthink Sally.

 

[Jill & Scooter]

Prayers for your mother in law. I’m not experienced enough to give you any real advice except maybe about test times. I always get a before bed test then based on that number I would set an alarm to test once during the night at least several nights a week. I varied the times between +6 and + 9 to try and catch his nadir. I am able to race home on my lunch and test and I try to do that at different times as much as possible. Now that Scooter is in lower numbers I get up to test more during the night to make sure he’s safe. Hope you see some better numbers soon!

 

[Ter and Sally]

It is common practice for treating DKA to use a lot of insulin (usually a longer acting plus a short acting) and keep the cat on a glucose drip. I would not let that be a concern. Since one of the issues with DKA is not enough food and not enough insulin, the kitty is getting a good dose of insulin and the glucose acts as both food and a means of controlling the insulin.

I forgot to say thank you for that. I knew they use the two types of insulin to get the ketones down but I didn't use my head about the glucose drip. I was just fixated on the ER dr telling me I test too much and not to test unless she seemed hypo.

 

[Ter and Sally]

Prayers for your mother in law. I’m not experienced enough to give you any real advice except maybe about test times. I always get a before bed test then based on that number I would set an alarm to test once during the night at least several nights a week. I varied the times between +6 and + 9 to try and catch his nadir. I am able to race home on my lunch and test and I try to do that at different times as much as possible. Now that Scooter is in lower numbers I get up to test more during the night to make sure he’s safe. Hope you see some better numbers soon!

Thanks for that.....and I guess maybe now for the next few days we won't be able to sleep so we can test. I work 30 miles from home and it's bottleneck traffic. I used to only be 7 miles from home and that was great. I came home a lot for lunch and could get home fast in an emergency. The most I could hope for is a plus 5 or 6 other than that I wouldn't be able to get enough sleep or get back to sleep. I've always wondered what reading would be helpful but if you are saying you do that a few times a week then I could do the +6 on the weekends.

 

[Sienne and Gabby (GA)]

While I've been known to mention that sleep is vastly overrated, no one expects you to be up every night testing. There may be times when you need to be sure Sally is safe but, hopefully, that's not a routine occurrence especially with the kind of commute you have. Most of us would try to get a test before we crawl into bed.

 

[Ter and Sally]

While I've been known to mention that sleep is vastly overrated, no one expects you to be up every night testing. There may be times when you need to be sure Sally is safe but, hopefully, that's not a routine occurrence especially with the kind of commute you have. Most of us would try to get a test before we crawl into bed.

That's funny, I guess you could never say that to a cat! I tell my husband, she sleeps, then we sleep. She can walk all over us in bed but we don't even straighten the bedsheets when she's sleeping
I'm the one who feels like I should test overnight, I have felt awful about being negligent about it. He says he knows about what happened overnight by the last night's test and he can actually pretty accurately tell what the reading is going be. But I want to know what actually happens overnight. The problem is I go to bed so much earlier than I used to. It's good for me to hear how other people manage it. I can't imagine if I was alone. FDMB is a Godsend to anyone going thru this alone.

 

[Sienne and Gabby (GA)]

I would still strongly encourage you and/or your husband to get at least one PM test in. Unless your husband has a crystal ball, I would not assume that you know where Sally's numbers are at any time. As a case in point, based on your husband's observation that he "knows" what happened based on the last night's test, I'd say that it's false confidence. It was not out of the ordinary at the beginning of our journey for Gabby's numbers to start in the 400s, drop to the 40s, and shoot back up the the 400s by the next pre-shot test. If I hadn't been testing, she could have been in dangerously lower numbers to say nothing of having missed the dose reduction and then increasing her dose.

Many cats will experience lower numbers overnight and without the PM information, you're missing half of your data. Many of us who have the greatest amount of experience here are very reticent to provide dose-related information without any routine PM tests. Your husband may know Sally but we don't and we are very numbers dependent.

 

[Ter and Sally]

I truly appreciate that, I see what you mean. We'll be trying to get more in the pm. Thank you again.